GW1--06050_Well Construction - GW1_20230920

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells I For Internal Use ONLY:
1.Well Contractor Information: I
Josh Plemmons 14.WATER ZONES •
FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1
4137-A R. ft.
-
NC Well Contractor Certification Number 15.OUTER CASING(for milli-eased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Clearwater Well Drilling Inc. I ft 1sa ft. I t9t t in. I S.Ye-Cl
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
'J O�] }�`�'��� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: L., C• �,�/L/ ft It. in. I
List all applicable well construction permits ff e.Couny.State.Variance.etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THiCttNESS MATERIAL
❑A cultural ft. ft. In.
Bti ❑Mrmicipal/Public
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) it• R. in. I
❑lndustrial/Com nercial DResidential Water Supply(shared) FROM I&.GROUT 1 •
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑brigation _ 1 it (90 n- C .tT e t rn t ll.t'd
Non-Water Supply Well:
❑Monitoring ❑Recovery rt. it
Injection Well: ft. R. I
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)'
ClAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
tt ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. H.
❑Geotherma!(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,sell/rock type.grain she.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) '• tt c It S C PC( 44 i;r-+.
4.Date Well(s)Completed:ty- ,, Well ID// r�('a R- �l l�,tt- �I CJ�
5a.Well Location: ZIJZ� l ,d J 9 7'g-ft. at-PS-it C re)L c e
C�n+h`t a Pad ct►FP ► �sft l�Rc�ft 9ranl
it, ft i
Facility/Owner Name Facility iD#(if applicable)
1I )nncl do 11✓ 24ve, he\11 1 . i....
PaySteal Address,City,and Zip '
21,REMARKS
oneemhe, SEP 2 0 2023
County Parcel identification No.(PIN) Irti :v n` �r.n[ ^.,:,:x6.4 g Lint:,$
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certi ati, : Enh 1 d'f `
(if well field,one lat/long is sufficient)
5L9'' 11 .Sr) N 3a" 51 50, w 8-I.7 2 3
Si fr-r of Certified Well Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary B signing this form,I hereby certh'that the wells)Ras(Were)constructed in accordance
viih ISA NCAC 02C.0100 or 15A NCAC 02C.0200 W ll Construction Standards and that a
7.Is this a repair to an existing well: [Yes or f o copy of this record has been provided to the welt owner.
If this is a repair,fill out known well construction information an ``explain the nature of the
repair under#21 remarks section or on the back of this Av. 23.Site diagram or additional well details:
You may use the back of this page to provide ditional well site details or well
8.Number of wells constructed: - construction details. You may also attach additi al pages if necessary.
For multiple Injection or non-water supply wells ONLY with the same construction,you con
submit one form. Q SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: tQ-it) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdJferent(example-3@,2000''and 2@100' construction to the following:
S�
10.Static water level below top of casing: l V (ft.) Division of Water Quality,Information Processing Unit,
If fluter level is above casing:use"+••)l Q 1617 Mail Service Center,Raleig ,NC 27699-1617
11.Borehole diameter. NA. v (in.) 24b.For infection Wells: In addition to send- the form to the address in 24a
�/� above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: l�/L construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY(WELLS ONLY: 1636 Mail Service Center,Raleig NC 27699-1636
13a.Yield(gpm) a v Method of test: R1.9 24c.For Water Supply&Inflection Wells: in a dition to sending the form to
the address(es)above,also submit one:copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county tcalth department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013